Does the use of renal artery stenting combined with aggressive medical therapy improve outcomes in patients with severe atherosclerotic renal artery stenosis?
In patients with severe atherosclerotic renal artery stenosis and hypertension or chronic kidney disease, renal artery stenting does not provide an additional benefit when added to comprehensive medical therapy that includes blood pressure and diabetes management and antiplatelet and lipid therapies. (LOE = 1b)
Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2013 Nov 13 [Epub ahead of print].
Randomized controlled trial (nonblinded)
Industry + govt
These investigators enrolled 947 patients with severe atherosclerotic renal artery stenosis (60% stenosis or more). Eligible patients also had either systolic hypertension while taking 2 or more antihypertensive medications or chronic kidney disease. Using concealed allocation, patients were randomized to receive either stenting plus medical therapy or medical therapy alone. Medical management included antiplatelet agents, antihypertensives, and lipid-lowering therapies. Specifically, all patients received candesartan with or without hydrochorthiazide, as well as the combination pill amlodipine-atorvastatin. Diabetes was managed according to clinical practice guidelines. The 2 groups had similar comorbidities at baseline. Overall, 90% of patients in each group had hyperlipidemia and approximately 30% had diabetes. The primary outcome was a composite of death from cardiovascular or renal causes, stroke, myocardial infarction, hospitalization for acute heart failure, worsening renal insufficiency, or the need for permanent dialysis. At a median follow-up of 43 months, there was no significant difference detected between the 2 groups in either the composite outcome (hazard ratio [HR] = 0.95; 95% CI, 0.76-1.17) or its individual components. All-cause mortality was also similar (HR = 0.80; 0.58-1.12).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.